95%(41)39 out of 41 people found this document helpful
This preview shows page 3 - 5 out of 8 pages.
2- Why wasn’t procedure followed by staff? The LPN did not follow procedure by not warning Nurse J of low oxygenation and blood pressure. The LPN did not alert the RN due to the ED being full of patients and low on staff. 3- Why wasn’t there enough staff in the ED? The ED did not call for more assistance resulting in them being short staffed. 5- Why were the staff members not asking for more help? A lack of communication between staff is why they did not call for more help. The cause of this event therefore was a lack of communication.Step four build your claim, such as “Poor communication between staff increased the chance of staff neglecting to follow policy (effect) which caused Mr. B to code and eventually die (event).”Step five is to create a list of actions that can be suggested to prevent such events from happening in the future, such as changing hospital policy to use additional staff with patients who have had mild sedation, or to have mandatory staff meetings to retrain everyone on hospital policy for monitoring patients with moderate sedation.
RCA and FMEAStep six is to write and post a review. I would create a flowsheet to clarify the instance to other staff members who were not present to teach them of the different plans we are implementing. This flowsheet could then be emailed to all employees.B.The changes I would make to protocols prevent a reoccurrence of future incidence wouldindicate that the nurses caring for the patient under moderate sedation should have another patient with a lower acuity. Staff education about care for moderately sedated patients should be discussed often. B1.Lewin’s change theory includes three stages which include unfreezing, change and refreezing. First is the unfreezing stage where the problem in identified, information collected, and staff notified of the need for change. People would release old habits that would make any change counterproductive. This could be accomplished by educating staff on the events surrounding Mr. B for them to understand the importance of these changes. (Cherry, 2017)The second stage is the action stage where the person making the change, decides what needs to be done, what change options there are, and puts them in motion. The third and final stage is the refreezing stage, this stage. By creating specific class dates and mandatory education for staff would result in better overall understanding from staff. (Cherry, 2017)The last step is the refreezing stage. At this step, the new change must be made the only
You've reached the end of your free preview.
Want to read all 8 pages?
Nursing, Root cause analysis, Failure mode and effects analysis, six-step process